Welcome to our Office Forms Today’s Date MM slash DD slash YYYY Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Birth date MM slash DD slash YYYY S.S. (last 4 digits)Sex Male Female Married Single Spouse’s NamePhoneHomeWorkCellPrimary Phone NumberHomeWorkCellEmail OccupationHow did you hear about us?Reason for your visitDo you have a Flexible Spending Account? Yes No INSURANCEVISION CARE INSURANCEDo you have Vision Care Insurance? Yes No Name of InsuranceID #Name of Primary on InsurancePrimary DOB MM slash DD slash YYYY Relationship to Insured Self Spouse Child Primary S.S. #MEDICAL INSURANCE(This information is requested because ocular medical problems may be covered under your medical health plan and not your vision care plan. You may also have routine coverage under your medical plan.) Do you have Medical Insurance? Yes No Name of InsuranceID #Name of Primary on InsurancePrimary DOB MM slash DD slash YYYY nformation is the same as in Vision Care Plan Relationship to Insured Self Spouse Child Primary S.S. #Please note that insurance may cover only part of your fees. The balance is your responsibility. If we do not accept direct payment from your insurance plan, payment is due at the time of service. A receipt will be given for you to submit to your insurance company. If you have a copay, that is due at the time of service. MEDICARE PATIENTS: Refractions are considered a non-medical service by Medicare, therefore this service is not covered by Medicare. Medicare patients are responsible for this $35 refraction fee which is in addition to the examination fee. At times, secondary insurances require copays which we may not be aware of until we receive the Explanation of Benefits. This is also your responsibility. CONTACT LENS WEARERS: : Insurance companies do not pay for contact lens (CL) fitting and evaluation. Yearly CL evaluation fees are separate from your eye examination fee. This fee is also applicable to being fit for a different type of CL. You are responsible for knowing your plan, what the insurance company covers, and if you need referrals and authorizations. Recently the number of different insurance companies has greatly increased. Even within one company, several different insurance programs can exist with varying benefits and requirements. Because of this, it is your responsibility to know and advise us of your insurance company’s requirements in advance. Please understand that if we provide you with a service and have not been advised in advance and accurately of your vision care/medical plan along with requirements and conditions, you will be responsible for all charges. I have read, understand, and agree to the above policies. I am aware that if I have no insurance, payment is due to the time services are rendered. I authorize Dr. Walter J. Shurminsky to submit claims to my insurance carrier for services provided. I request payments of all benefits for such services to be made directly to Dr. Walter J/ Shurminsky. Signature*Date MM slash DD slash YYYY Parent or Guardian name First Last Relationship to Patient: Parent HIPAAReceipt of Notice of Privacy Practices Written Acknowledgement and Consent FromA copy of the Privacy Practices is permanently kept in our waiting room. Please read and understand your rights as guaranteed by the federal government. These are the policies we follow to protect your personal health information. If you would like a copy, please ask at the reception desk. I have read/received a copy of Privacy Practices. I give my consent for the practice of Dr. Shurminsky Jr., O.D. to use and disclose my protected health information (PHI) to carry out treatment, payment, and healthcare operations (TPO). The practice may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care. I may revoke this consent in writing except to the extent that the practice made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the practice may decline to provide treatment to me. Patient NameSignature of Patient or Legal Guardian*Date MM slash DD slash YYYY Name of Legal Guardian Δ
